Members may visit a dentist of their choice, but out-of-pocket costs may vary depending on dentist selection. Visit Delta Dental to find a participating dentist. ID cards can be requested through DDMO.

Two additional cleanings allowed per calendar year for members who are pregnant, diabetic, have a suppressed immune system or a history of periodontal therapy. To be eligible, members must submit a completed Self-Report form unless periodontal therapy has already been reported on claims.

Coinsurance amounts apply after the $50 individual deductible is met under either Basic and Restorative or Major Services combined.

Limitations & Exclusions

Type

Service

Description

Limitations

Alternative Treatments

If available, DDMO will cover the least costly treatment

Coverage

Coverage is limited to $1,000 per person per calendar year

Preauthorizations

Non-emergency procedures with a cost estimate of more than $200 may be subject to a preauthorization. This provides an advanced estimate of what the dental coverage will pay and what the member will pay.

Transferring Care

If two or more providers are used for the same procedure, benefits will not exceed what would have been paid for one provider.

Exclusions

Analgesic Services

Includes nitrous oxide

Cosmetic Services

Congenital Malformations

Except newborns with congenital dental defects

Dentures

Excludes coverage of lost or stolen dentures, as well as adjustments for the first six months

DDMO offers two provider networks: the Delta Dental PPO Network and the Delta Dental Premier Network. Both networks offer members cost-control and claim-filing benefits. However, out-of-pocket expenses may be higher with the Delta Dental Premier Network.

If utilizing a non-network provider, the member will be responsible for paying the provider in full, as well as submitting a claim form to DDMO. The out-of-pocket costs will most likely be higher.

The cost of the visit will also depend on the type of service the member received.

Diagnostic and preventive services are covered at 100 percent.

Members receiving basic and restorative or major services must meet a $50 deductible. Once the deductible is met, members will pay coinsurance (see Benefit Chart for more information).